International Aviation – Week 2 Safety Notes

Acknowledgement of Country

• Griffith University recognises the Traditional Custodians of the land and pays respect to Elders—past, present and emerging—extending this respect to all Aboriginal and Torres Strait Islander peoples.

Lecture Scope (Week 2 – Safety)

• Aviation‐safety overview

• Accident vs. proactive safety philosophies

• ICAO management frameworks (Annex $13$ vs. Annex $19$)

• Safety-investigation systems and authorities

• Australian safety agencies: CASA, ATSB, Airservices, DITRDCA

• Strategic and audit programmes: $USOAP$, $IOSA$, $NASP$, etc.

Aviation-Safety Foundations

• Definition (ICAO Annex $19$):

  • “A state in which the possibility of harm to persons or property is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety-risk management.”

• Key characteristics

  • Focus on acceptable (not zero) risk in a complex, high-risk industry

  • Continuous, dynamic and system-wide activity (rules, tech, training, oversight)

• Two complementary views of safety

  1. Human-Factors View

  • Human error = primary causal agent ⇒ study behaviours, improve training, design & procedures

  1. Safety-Management View

  • Error = symptom of deeper system weaknesses ⇒ fix organisational, cultural & procedural roots

Annex $13$ vs. Annex $19$ (Reactive ↔ Proactive)

• Annex $13$ – Aircraft Accident & Incident Investigation

  • International standards for evidence collection, stakeholder involvement, report writing

  • Purpose = Prevention of recurrence, not blame ⇒ fosters a “Just Culture”

  • Reactive: only triggered after an occurrence

• Annex $19$ – Safety Management

  • Mandates State Safety Programme ($SSP$) & organisational Safety Management System ($SMS$)

  • Integrates lessons from Annex $13$ into day-to-day risk control

  • Proactive: anticipates & mitigates hazards before accidents

ICAO Global Aviation Safety Plan (GASP $2023$–$2025$)

• Vision $=0$ fatalities in commercial ops by $2030$+

• Aligns with UN SDGs (safe, resilient, sustainable aviation)

• Six global goals

  1. Reduce operational‐safety risks (focus on data-driven prevention)

  2. Strengthen States’ safety oversight

  3. Implement effective $SSP$

  4. Enhance regional collaboration (RASGs, RSOOs)

  5. Expand industry programmes & data sharing

  6. Improve infrastructure (runways, $ANS$, ATC tech)

• Global High-Risk Categories (G-HRC)

  • Controlled Flight Into Terrain (CFIT)

  • Loss of Control In-Flight (LOC-I)

  • Mid-Air Collision (MAC)

  • Runway Excursion (RE)

  • Runway Incursion (RI)

• Implementation tools

  • National Aviation Safety Plans ($NASP$)

  • Regional Aviation Safety Plans ($RASP$)

  • Global Aviation Safety Roadmap (Doc $10161$ → how to do it)

  • Three-year review cycle & continuous monitoring

Safety-Investigation Systems

• Each ICAO State must create an Accident Investigation Authority (AIA) independent of regulator/service provider (e.g., NTSB, ATSB)

• Principles

  • Independence avoids political/commercial influence

  • State of Occurrence leads; States of Registry, Operator & Manufacturer participate

  • Evidence: physical wreckage, $FDR/CVR$ data, witness testimony

• Four pillars of $SMS$ (ICAO)

  1. Safety Policy & objectives (leadership, accountability, ERP)

  2. Safety-Risk Management (hazard ID, risk assessment, mitigation)

  3. Safety Assurance (monitoring, audits, continuous improvement)

  4. Safety Promotion (training, comms, safety culture)

• Investigation challenges

  • Multinational politics & coordination

  • Balancing transparency with privacy (e.g., releasing $CVR$ audio)

  • Psychological toll on investigators

  • Use of CICTT occurrence categories for global trend analysis

• Why investigate?

  • Identify root causes, prevent recurrences, save money, improve morale & reputation

Global Safety-Audit & Oversight Programmes

• $USOAP$ (CMA) – ICAO: audits $8$ critical elements of State oversight; scores published for transparency

• $IASA$ – FAA: Category $1$ (meets SARPs) vs. Category $2$ (doesn’t) for U.S. market access

• $SAFA$ / EU Blacklist – EASA: ramp inspections & bans unsafe foreign airlines

• $IOSA$ – IATA: bi-annual airline audit prerequisite for IATA membership

• Other systems

  • $USAP ext{-}CMA$ (aviation security – Annex $17$)

  • ICAO $SSP$ requirements (State level, proactive)

Australian Aviation-Safety Architecture

• Civil Aviation Safety Authority (CASA)

  • Regulates safety, licenses personnel, registers aircraft, certifies aerodromes

• Australian Transport Safety Bureau (ATSB)

  • Independent investigator; publishes safety recommendations; runs confidential $REPCON$ scheme

• Airservices Australia

  • Government-owned; provides $ATC$, $ARFF$, navigation & comms systems

• Department of Infrastructure, Transport, Regional Development, Communications & the Arts (DITRDCA)

  • Develops policy & legislation; coordinates with ICAO; oversees national $SSP$

• National programmes

  • Australia holds FAA $IASA$ Category $1$, participates in $USOAP$ (latest audit $2023/24$ – effective oversight)

  • NASP $2024$–$2027$ aligns with GASP goals & local risks

  • $REPCON$ fosters non-punitive reporting culture

CASR “Bubble Diagram” – Key Regulation Clusters

• Flight Operations (Yellow; Part $91$ core)

  • Certification (Part $119$), transport ops (Parts $121,129,131{-}135$), sport & drones (Parts $101,103,105,149$)

• Certification / Airworthiness (Dark Blue; Part $21$ plus $22$, $23$, $25{-}33$, $35$, $39$, $90$)

• Continuing Airworthiness (Orange; Part $42$) + Standards (Part $43$) + Maintenance Orgs (Part $145$)

• Licensing

  • AME (Red; Part $66$) + training orgs (Part $147$)

  • Flight crew (Green; Part $61$) + medical (Part $67$) + training orgs (Parts $141$/$142$)

• ATC & Airspace (Light Blue; Part $65$) + aerodromes $139$, ATC training $143$, CNS $171{-}176$

• Registration (Grey; Parts $45{-}47$, $200{-}202$)

• Legal foundations: Civil Aviation Act, Airspace Act, CARs/CASRs

Risk-Management Foundations

• Risk formula $\text{Risk}=\text{Severity}\times\text{Likelihood}$

• Seven-step assessment process

  1. Identify hazards (observe, review data, consult staff)

  2. Identify associated risks & contributing factors (record in register)

  3. Evaluate (severity/likelihood matrix ⇒ prioritise)

  4. Mitigate (apply Hierarchy of Controls + $ALARP/SFAIRP$)

  5. Record & implement actions (assign owners, deadlines)

  6. Monitor effectiveness (feedback, KPIs)

  7. Review & update (at least annually or after change)

• Categories of acceptability (graph)

  • Unacceptable → Tolerable (with $ALARP$) → Broadly acceptable

• Bow-Tie model

  • Centre: Top Event (e.g., “car skids on wet road” / “aircraft CFIT”)

  • Left: Threats + preventive controls

  • Right: Consequences + mitigative controls

• Hierarchy of Controls (most → least effective)

  1. Elimination

  2. Substitution

  3. Engineering controls

  4. Administrative controls

  5. PPE

Safety Management Systems – What Maturity Delivers

• Embeds the four pillars to:

  • Reinforce critical procedures (deicing, W&B, etc.)

  • Drive accountability through audits & data analytics

  • Support decision-making under stress (tools, SOPs)

  • Enable a Just Culture for continuous learning

• Key reminder: “Regulation provides the framework; daily frontline risk management keeps aviation safe.”

Human Factors & Non-Technical Skills (NTS)

• Technical skills = hard, task-based competencies (tested via exams, sims)

• NTS = communication, leadership, situational awareness, decision-making (assessed via NOTECHS)

• Pilot HF training evolution

  1. CRM – classroom theory (teamwork, leadership)

  2. LOFT – simulator scenarios using CRM skills in realistic contexts

  3. TEM – threat & error management tailored to actual LOSA data

• NASA $1979$ workshop seeded global CRM mandate; now integral to annual pilot training (+ fatigue, stress modules)

Investigator Training Pathway

• Three formal phases

  1. Basic classroom (laws, ethics, Annex $13$, safety at site)

  2. On-the-job (shadowing, evidence preservation, interviewing)

  3. Advanced course (CVR/FDR reading, fire/origin analysis, report writing)

• ATSB pathway example

  • Recruits often ex-pilots/engineers → internal courses → supervised field work → external programmes (e.g., Cranfield MSc) → CPD via ISASI

Case Studies & Lessons

Weight & Balance Fundamentals

• Weight = total aircraft mass (fuel, pax, bags, cargo)

• Balance = distribution relative to CG limits (forward CG = difficult rotation; aft CG = pitch instability)

Air Midwest Flight $5481$ (USA, $08$ Jan $2003$)

• Factors

  • Actual weight $\approx150\,\text{kg}$ heavier; CG aft of limit (outdated pax/bag averages)

  • Elevator-cable mis-rigging restricted pitch control

• Outcome: Stall after take-off; $21$ fatalities

• Aftermath

  • FAA & industry updated standard-weight tables (avg pax $88\,\text{kg}$ vs. historical $80\,\text{kg}$)

  • Highlighted Goal $1$ & $2$ gaps in $GASP$ → triggered SEIs on W&B and maintenance oversight

Phenom $300$ Crash (Provo, Utah, $02$ Jan $2023$)

• Visible freezing drizzle; pilot skipped de-icing, de-activated Wing-Stab anti-ice

• Stall seconds after lift-off; $1$ fatality, $3$ injuries

• Demonstrates direct link between procedural non-compliance & aerodynamic failure; underscores SMS role in reinforcing SOPs/Just Culture

Case-Study Mapping to GASP Cycle

Strategic, Voluntary & Industry-Led Safety Systems

• ICAO GASP / RASG / ADREP = global‐strategic & data-sharing backbone

• Europe: $ECCAIRS$ harmonises incident data; $ITSA$ coordinates best-practice investigation resources

• Industry programmes

  • $IOSA$ (global airline audit)

  • Flight Safety Foundation (toolkits, research)

  • $CAST$ / $ASIAS$ (U.S. collaborative data-driven safety)

  • Confidential reporting: $ASRS$ (USA), $REPCON$ (AUS)

• Benefits: performance-based, cooperative safety culture; move “beyond compliance”.

Infographics for Aviation Professionals

• Visual, dual-coded communication: converts dense safety data (e.g., HFACS, risk models) into quick-grasp insights

• Enhances synthesis, critical thinking & professional briefings

• Widely used in $SMS$ docs, ICAO/eASA summaries, FRMS reports

• Canvas task: design a $PDF$ infographic (rubric provided) using Annex references

Key Takeaways

• Safety = proactive, system-wide, data-driven management of acceptable risk.

• Annex $13$ investigations feed Annex $19$ SMS/SSP loops; both are essential.

• GASP provides strategy; Roadmap, NASP & RASP operationalise it; continuous monitoring closes the loop.

• Strong national framework (CASA/ATSB/Airservices/DITRDCA) + mature $SMS$ on the frontline ⇒ safer skies.

• Human factors, NTS, and robust risk-assessment tools (Bow-Tie, Hierarchy, Matrix) turn regulations into everyday safety behaviours.